Does Subdural Hematoma Present with Headache?
Yes, subdural hematoma commonly presents with headache, though it is neither universal nor specific—headache occurs in approximately 22.6% of chronic subdural hematoma cases and can be the sole presenting symptom in some patients.
Frequency and Clinical Patterns
Headache is present in only about one-quarter of chronic subdural hematoma (CSDH) patients (22.6% in a large surgical series of 1,080 patients), making it less common than many clinicians assume 1
Age significantly influences headache presentation: younger patients (mean age 59.8 years) are substantially more likely to report headache compared to older patients (mean age 75.7 years without headache), suggesting that elderly patients may have diminished pain perception or altered symptom reporting 1
Headache can be the only presenting symptom in some cases, even with acute spontaneous subdural hematoma, as documented in post-spinal anesthesia cases 2
Mechanism of Headache in Subdural Hematoma
The pathophysiology differs from typical assumptions about intracranial pressure:
Increased intracranial pressure is NOT the primary mechanism: Signs of elevated ICP (papilledema, nausea/vomiting) are rare in CSDH patients—papilledema was found in only 0.4% of 238 examined patients, and nausea/vomiting in only 3.0% 1
Hematoma pressure does not correlate with headache: Direct measurement showed no significant difference in hematoma pressure between patients with headache (17.1 mmH₂O) versus without (18.4 mmH₂O) 1
Midline shift is the key factor: The ratio of midline shift to hematoma thickness was significantly greater in patients with headache, suggesting that stretching or twisting of pain-sensitive meninges and meningeal vessels is the actual cause of headache 1
Critical Differential Diagnosis Considerations
When evaluating subdural hematoma in the context of headache:
Subdural hematoma must be differentiated from spontaneous intracranial hypotension (SIH): MRI of brain and spine should be performed when subdural hematoma/hygroma presents with orthostatic headache or lacks typical risk factors (trauma, coagulopathy, alcohol misuse) 3
Subdural hematoma can mimic hepatic encephalopathy: While HE and subdural hematoma share cognitive symptoms, subdural hematoma is commonly accompanied by other neurological symptoms such as hemiplegia, helping distinguish the two 3
The classic presentation includes confusion, ataxia, and hemiparesis in addition to headache, and can mimic dementia, stroke, TIA, neoplasm, or normal pressure hydrocephalus in older adults 4
Management Implications Based on Headache Presentation
Asymptomatic patients or those with isolated headache can be managed conservatively with serial neuroimaging by CT, whereas patients with focal neurologic signs should be considered for surgical intervention 4
Small or asymptomatic subdural hematomas should be managed conservatively while treating any underlying CSF leak if present; symptomatic hematomas with significant mass effect may require burr hole drainage 3
Beware of delayed presentations: Patients with initially mild headache that resolves may still develop focal neurological deficits days to weeks later due to cerebral hemispheric swelling and ischemia, even without hematoma expansion 5
Common Pitfalls to Avoid
Do not assume absence of headache rules out subdural hematoma: The majority (77.4%) of CSDH patients do NOT complain of headache, even with thick hematomas and definite midline shift 1
Do not dismiss isolated headache in elderly patients: Older adults are less likely to report headache but may still have significant subdural collections requiring intervention 1
Do not attribute all headache to increased ICP: The mechanism in subdural hematoma is primarily meningeal stretch rather than elevated pressure, which has implications for treatment approach 1
Consider subdural hematoma in post-procedural headache: Acute spontaneous subdural hematoma can occur after spinal anesthesia and may present with headache alone, requiring distinction from post-dural puncture headache 2